Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Drug EHB Deductible, Combined In/Out of Network, Family Per Group
per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person
per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual
Not Applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Group
per group not applicable
Drug EHB Deductible, In Network (Tier 1), Family Per Person
$3000 per person
Drug EHB Deductible, In Network (Tier 1), Individual
$3,000
Drug EHB Deductible, In Network (Tier 2), Family Per Group
per group not applicable
Drug EHB Deductible, In Network (Tier 2), Family Per Person
$3000 per person
Drug EHB Deductible, In Network (Tier 2), Individual
$3,000
Drug EHB Deductible, Out of Network, Family Per Group
per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person
per person not applicable
Drug EHB Deductible, Out of Network, Individual
Not Applicable
Design Type
Not Applicable
Disease Management Programs Offered
Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Pain Management, Pregnancy
EHB Percent of Total Premium
1
First Tier Utilization
0%
Limited Cost Sharing Plan Variation - Estimated Advanced Payment
$0.00
New/Existing Plan
Existing
Notice Required for Pregnancy
No
Is a Referral Required for Specialist?
No
Medical EHB Deductible, Combined In/Out of Network, Family Per Group
per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person
per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual
Not Applicable
Medical EHB Deductible, In Network (Tier 1), Family Per Group
$6250 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person
$3125 per person
Medical EHB Deductible, In Network (Tier 1), Individual
$3,125
Medical EHB Deductible, In Network (Tier 2), Family Per Group
$6250 per group
Medical EHB Deductible, In Network (Tier 2), Family Per Person
$3125 per person
Medical EHB Deductible, In Network (Tier 2), Individual
$3,125
Medical EHB Deductible, Out of Network, Family Per Group
$12500 per group
Medical EHB Deductible, Out of Network, Family Per Person
$6250 per person
Medical EHB Deductible, Out of Network, Individual
$6,250
Plan Effective Date
1/1/2026
Plan Expiration Date
12/31/2026
Second Tier Utilization
100%
Wellness Program Offered
No